President Obama’s signing of his landmark health care legislation on March 22, 2010, after almost a century of deliberation about how to improve the US health care system, marked the beginning of a new chapter in US history marked by the guarantee of medical insurance for all Americans. What will happen now? The lessons learned from 50 years of universal health care in Japan indicate the need for careful administration of universal health care in the United States.
Japan’s universal health care system was established in 1961. Japan was ranked first among 191 countries in the World Health Organization’s rankings of health systems for 1997 and 1999, and Japan’s men and women have the longest life expectancies in the world. The Japanese health care system offers patients easy access to quality care at low cost, which makes the system popular with patients. However, the low cost of care and easy access to care have contributed to serious problems: over-access, inefficient allocation of health care resources, dissatisfaction among health care providers, and lack of investment in cutting-edge research.
Medical costs in Japan are kept low to control national health care expenditures. Medical fees in Japan are calculated on the basis of “points of remuneration for medical services” assigned by the Ministry of Health, Labour and Welfare and are severely controlled. For example, the allowable fees for a half hour and for an hour of cardiac massage are only $25 and $29, respectively. Furthermore, a patient pays only 30% of the total fees under the current system.
The Japanese universal health care system also allows anyone to access any medical institution at any time. Additional fees are charged for consulting a specialist or accessing care at night, but these fees are modest.
The low costs and easy access strain the capacity of the health care system. Patients often visit hospitals for minor conditions because the cost of seeing a physician and receiving medication at a hospital is sometimes cheaper than the cost of self-medication with over-the-counter drugs.
Many Japanese people regard emergency centers as open-24-hours convenience stores and feel free to go to emergency centers at night even when they become sick during the day and could make time to go to a clinic in the daytime. In 2006, the average number of annual doctor consultations per capita in Japan was 13.6, compared with 3.8 in the United States. Eventually, easy access for all reduces the medical resources available for patients with severe conditions.
Furthermore, the Japanese people’s behavior under the current health care system leaves physicians and other health care providers feeling overworked. In addition, the too-easy access and severe cost control in the current Japanese health care system make it very difficult to provide adequate salary support for health care providers. These poor conditions reduce health care providers’ satisfaction with their work and predispose them to burnout.
Therefore, Japan has an urgent need to change the current low-cost, easy-access system such that primary care physicians serve as gatekeepers limiting access.
Japan also needs to adjust resource allocation in its health care system to promote cutting-edge research and ensure patients access to cutting-edge medicine. Currently, the availability of high-quality medical care for everyone makes patients less willing to participate in clinical trials of novel treatments.
Further, because of limited governmental support and burnout, the proportion of clinical investigators who can conduct cutting-edge research is relatively low.
Clearly, compared with the United States, Japan lags behind in creating new clinical evidence to spur improvements in health care. Japan needs to develop a health care budget that promotes and facilitates high-quality clinical trials in addition to focusing on comprehensive universal health care.
In Japan, various improvements in the health care system are in progress, including enhancement of the use of primary care physicians to control patients’ too-easy access to health care, construction of a more efficient multidisciplinary medical service, increase in the funding of cutting-edge medical technology, and development of infrastructure for clinical trials. Whether these measures will be sufficient to bring about higher-quality comprehensive care remains to be determined.
Equal medical care for everyone, cutting-edge medicine, and clinical trials, or all of the above? As the United States begins a new chapter in its health care history and seeks the best balance with the limited resources available, policy makers can draw on key lessons from the Japanese experience.
REIKO HORI, Friends of Rare Disease Patients, Tokyo; CHIYO K. IMAMURA, PHD, BCOP, Department of Clinical Pharmacokinetics and Pharmacodynamics, School of Medicine, Keio University, Tokyo; NAOTO T. UENO, MD, PHD, Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center